- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,840.50 / $12,840.50 / $12,840.50
| Facility | | $12,840.50 | $12,840.50 | $12,840.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,869.87 / $10,217.79 / $10,217.79
| Facility | | $9,869.87 | $10,217.79 | $10,217.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,027.12 / $8,492.76 / $15,821.06
| Facility | | $6,027.12 | $8,492.76 | $15,821.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $950.00 / $950.00 / $950.00
| Facility | | $950.00 | $950.00 | $950.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,027.12 / $8,492.76 / $15,595.63
| Facility | | $6,027.12 | $8,492.76 | $15,595.63 |